The incidence of feeding and swallowing disorders refers to the number of new cases identified in a specified time period. The prevalence of feeding and swallowing disorders refers to the number of children who are living with feeding and swallowing problems in a given time period.

It is assumed that the incidence of feeding and swallowing disorders is increasing because of the improved survival rates of children with complex and medically fragile conditions (Lefton-Greif, 2008; Lefton-Greif, Carroll, & Loughlin, 2006; Newman, Keckley, Petersen, & Hamner, 2001) and the improved longevity of persons with dysphagia that develops during childhood (Lefton-Greif et al., 2017).

Estimated reports of the incidence and prevalence of pediatric feeding and swallowing disorders vary widely due to factors including variations in the conditions and populations sampled, how feeding disorders and/or swallowing impairment are defined, and the choice of assessment methods and measures (Arvedson, 2008; Lefton-Greif, 2008). The data below reflect this variability:

• According to the Centers for Disease Control and Prevention (CDC), survey interviews indicated that within the past 12 months, 0.9% of children (approximately 569,000) ages 3–17 years are reported to have swallowing problems (Bhattacharyya, 2015; Black, Vahratian, & Hoffman, 2015).
• An estimated 116,000 newborn infants are discharged from short-stay hospitals with a diagnosis of feeding problems, according to the National Hospital Discharge Survey from the CDC (National Center for Health Statistics, 2010). Prevalence is estimated to be 30%–80% for children with developmental disorders (Arvedson, 2008; Brackett, Arvedson, & Manno, 2006; Lefton-Greif, 2008; Manikam & Perman, 2000).
• Oropharyngeal dysphagia and/or feeding dysfunction in children with cerebral palsy is estimated to be 19.2%–99.0%. Rates increase with greater severity of cognitive impairment and decline in gross motor function (Benfer et al., 2014; Calis et al., 2008; Erkin, Culha, Sumru, & Gulsen, 2010).
• The odds of having a feeding problem increase by 5 times in children with autism spectrum disorder (ASD) compared with children who do not have ASD (Sharp et al., 2013).
• ARFID rates are estimated to be 1.5%–13.8% in children between the ages of 8 and 18 years with suspected gastrointestinal problems or eating disorders (Eddy et al., 2015; Fisher et al., 2014). Cases of ARFID are reported to have a greater likelihood in males and children with gastrointestinal symptoms, a history of vomiting/choking, and a comorbid medical condition (Fisher et al., 2014).
• Prevalence rates of oral dysphagia in children with craniofacial disorders are estimated to be 33%–83% (Caron et al., 2015; de Vries et al., 2014; Reid, Kilpatrick, & Reilly, 2006).

Disruptions in swallowing may occur in any or all of the phases of swallowing—oral preparatory, oral transit, pharyngeal, and esophageal. Signs and symptoms vary based on the phase(s) affected and the child's age and developmental level. They may include the following:

• Back arching.
• Breathing difficulties when feeding that might be signaled by
  • increased respiratory rate;
  • changes in normal heart rate (bradycardia or tachycardia);
  • skin color change such as turning blue around the lips, nose and fingers/toes (cyanosis);
  • temporary cessation of breathing (apnea);
  • frequent stopping due to uncoordinated suck-swallow-breathe pattern; and
  • desaturation (decreasing oxygen saturation levels).
• Coughing and/or choking during or after swallowing.
• Crying during mealtimes.
• Decreased responsiveness during feeding.
• Difficulty chewing foods that are texturally appropriate for age (may spit out or swallow partially chewed food).
• Difficulty initiating swallowing.
• Difficulty managing secretions (including non-teething-related drooling of saliva).
• Disengagement/refusal shown by facial grimacing, facial flushing, finger splaying, or head turning away from food source.
• Frequent congestion, particularly after meals.
• Frequent respiratory illnesses.
• Gagging.
• Loss of food/liquid from the mouth when eating.
• Noisy or wet vocal quality during and after eating.
• Taking longer to finish meals or snacks (longer than 30 minutes).
• Refusing foods of certain textures or types.
• Taking only small amounts of food, overpacking the mouth, and/or pocketing foods.
• Vomiting (more than typical “spit-up” for infants).

Underlying etiologies associated with pediatric feeding and swallowing disorders include

• complex medical conditions (e.g., heart disease, pulmonary disease, gastroesophageal reflux disease [GERD], delayed gastric emptying);
• developmental disability (i.e., disability with onset before the age of 22 that warrants lifelong or extended medical, therapeutic, and/or residential supports and is attributable to a mental or physical impairment or a combination of mental and physical impairments);
• factors affecting neuromuscular coordination (e.g., prematurity, low birth weight, hypotonia, hypertonia);
• genetic syndromes (e.g., Down syndrome, Pierre Robin Sequence, Prader–Willi, Rett syndrome, Treacher Collins syndrome, 22q11 deletion);
• medication side effects (e.g., lethargy, decreased appetite);
• neurological disorders (e.g., cerebral palsy, meningitis, encephalopathy, pervasive developmental disorders, traumatic brain injury, muscle weakness in face and neck);
• sensory issues as a primary cause or secondary to limited food availability in early development (e.g., in children adopted from institutionalized care; Beckett et al., 2002, Johnson & Dole, 1999);
• structural abnormalities (e.g., cleft lip and/or palate and other craniofacial abnormalities, laryngomalacia, tracheoesophageal fistula, esophageal atresia, choanal atresia);
• behavioral factors (e.g., food refusal); and
• socio-emotional factors (e.g., parent–child interactions at mealtimes).

Atypical eating and drinking behaviors can develop in association with dysphagia, aspiration, or a choking event. They may also arise in association with sensory disturbances (e.g., hypersensitivity to textures), stress reactions (e.g., when trying new foods), or undetected pain (e.g., teething, tonsillitis). See for example, Dodrill (2017) and Manikam and Perman (2000).

Speech-language pathologists (SLPs) play a central role in the assessment, diagnosis, and treatment of infants and children with swallowing and feeding disorders. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).

Appropriate roles for SLPs include the following:

• Providing prevention information to families of children at risk for pediatric feeding and swallowing disorders as well as to individuals working with those at risk.
• Educating other professionals on the needs of children with feeding and swallowing disorders and the role of SLPs in diagnosing and managing these disorders.
• Participating in decisions regarding the appropriateness of instrumental evaluation procedures and follow-up.
• Conducting a comprehensive assessment, including clinical and instrumental evaluations.
• Considering culture as it pertains to food choices, perception of disabilities, and beliefs about intervention (Davis-McFarland, 2008).
• Diagnosing pediatric oral and pharyngeal swallowing disorders (dysphagia).
• Recognizing signs of ARFID and making an appropriate referral.
• Referring the patient to other professionals as needed to rule out other conditions, determine etiology, and facilitate patient access to comprehensive services.
• Recommending a safe swallowing and feeding plan for the Individualized Family Service Plan (IFSP), Individualized Education Program (IEP), or 504 Plan.
• Counseling children and their families to provide education to prevent complications related to feeding and swallowing disorders.
• Serving as an integral member of an interdisciplinary feeding and swallowing team.
• Providing quality control and risk management.
• Consulting and collaborating with other professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate (see ASHA's resources on interprofessional education/interprofessional practice (IPE/IPP) and person- and family-centered care).
• Remaining informed of research in the area of pediatric feeding and swallowing disorders while helping to advance the knowledge base related to the nature and treatment of these disorders.
• Advocating for families and individuals with feeding and swallowing disorders at the local, state, and national levels.

Experience in adult swallowing disorders does not qualify an individual to provide swallowing assessment and intervention for children. An understanding of adult anatomy and physiology of the swallow may provide a good basis for understanding dysphagia in children; however, additional knowledge and skills specific to pediatric populations are needed. As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be educated and appropriately trained to do so.

As indicated in the Speech-Language Pathology Assistant Scope of Practice (ASHA, 2013), speech-language pathology assistants (SLPAs) may demonstrate or share information with patients, families, and staff regarding feeding strategies developed and directed by the SLP. However, they may not perform diagnostic evaluations of feeding and swallowing, including swallowing screenings/checklists; tabulate or interpret results and observations of feeding and swallowing evaluations performed by SLPs; or perform oral pharyngeal swallow therapy with bolus material.

Assessment and treatment of swallowing and swallowing disorders may require use of appropriate personal protective equipment.

Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; WHO, 2001), comprehensive assessment is conducted to identify and describe

• impairments in body structure and function, including the swallowing phases that are affected;
• co-morbid deficits or conditions, such as developmental disabilities or syndromes;
• limitations in activity and participation, including the impact on overall health (including nutrition and hydration) and the child's ability to participate in routine activities (e.g., family meals, meals at daycare and school, birthday celebrations with friends);
• contextual (environmental and personal) factors that serve as barriers to or facilitators to successful nutritional intake (e.g., child's food preferences; family support in implementing strategies for safe eating and drinking); and
• the impact of feeding and swallowing impairments on quality of life of the child and family.

See Person-Centered focus on Function: Pediatric Feeding and Swallowing for examples of assessment data consistent with ICF.

When assessing feeding and swallowing disorders in the pediatric population, clinicians consider the following factors:

• Congenital abnormalities and/or chronic conditions can affect feeding and swallowing function.
• Feeding skills of premature infants will be consistent with neurodevelopmental level rather than chronological age or adjusted age.
• Positioning limitations and abilities (e.g., children who are wheelchair dependent) may affect intake and respiration.
• Infants cannot verbally describe their symptoms, and children with reduced communication skills may not be able to adequately do so—clinicians must rely on a thorough case history; data from monitoring devices (e.g., in the neonatal intensive care unit (NICU); and nonverbal forms of communication (e.g., behavioral cues signaling feeding or swallowing problems).

As infants and children grow and develop, the absolute and relative size and shape of oral and pharyngeal structures change. See figures below.

Anatomical and physiological differences include the following:

• In infants, the tongue fills the oral cavity and the velum hangs lower. The hyoid bone and larynx are positioned higher than in adults, and the larynx elevates less than in adults during the pharyngeal phase of the swallow.
• Once the infant begins eating pureed food, each swallow is discrete, and the oral and pharyngeal phases are similar to those of an adult (although with less elevation of the larynx).
• As the child matures, the intraoral space increases as the mandible grows down and forward, and the oral cavity elongates in the vertical dimension. The space between the tongue and the palate increases, and the larynx and the hyoid bone lower, elongating and enlarging the pharynx (Logemann, 1998).

Chewing matures as the child develops (see e.g., Gisel, 1988; Le Révérend, Edelson, & Loret, 2014; Wilson, & Green, 2009). Concurrent medical issues may affect this timeline. Foods given during the assessment should be consistent with the child's current level of chewing skills.

Team Approach

A team approach is necessary for appropriately diagnosing and managing pediatric feeding and swallowing disorders, as the severity and complexity of these disorder vary widely in this population (McComish et al., 2016). The SLP who specializes in feeding and swallowing disorders typically leads the professional care team in the clinical or educational setting.

In addition to the SLP, team members may include

• family and/or caregivers;
• dietitian;
• lactation consultant (infants);
• nurse (clinical and/or school);
• occupational therapist;
• physician (e.g., pediatrician, neonatologist, otolaryngologist, gastroenterologist);
• physical therapist;
• psychologist;
• social worker;
• classroom teacher; and
• classroom teaching assistant.

Additional medical and rehabilitation specialists may be included, depending on the type of facility, the professional expertise needed, and the specific population being served.

See ASHA's resources on dysphagia teams, interprofessional education/interprofessional practice [IPE/IPP], and person- and family-centered care.

Clinical Evaluation

A clinical evaluation of swallowing and feeding is the first step in determining the presence or absence of a swallowing disorder.

The evaluation addresses the swallowing-based activities of eating, drinking, and secretion management and may include oral hygiene (brushing, flossing, rinsing) and the management of oral medications.

SLPs conduct assessments in a manner that is sensitive and responsive to the family's cultural background, beliefs, and preferences for treatment. Families are encouraged to bring food and drink common to their household and utensils typically used by the child. Typical feeding practices are used during assessment (e.g., if the child is typically fed sitting on a parent's lap, then this is observed during the assessment).

The clinical evaluation typically includes the following:

• Case history, based on a comprehensive review of medical/ clinical records, as well as interviews with the family and other health care professionals.
• Assessment of overall physical, social, behavioral, and communicative development.
• Structural assessment of the face, jaw, lips, tongue, hard and soft palate, oral pharynx, and oral mucosa.
• Functional assessment of muscles and structures used in swallowing, including assessment of symmetry, sensation, strength, tone, range and rate of motion, and coordination of movement.
• Observation of head–neck control, posture, oral and pharyngeal reflexes, and involuntary movements and responses in the context of the child's developmental level.
• Observation of the child eating or being fed by a family member or caregiver using foods from the home and typically used utensils as well as utensils that the child may reject or that may be challenging.
• Functional assessment of swallowing ability, including but not limited to typical developmental skills and task components—suckling and sucking in infants, mastication in older children, oral containment, and manipulation and transfer of the bolus.
• Assessment of behavioral factors, including but not limited to (a) acceptance of pacifier, nipple, spoon, and cup and (b) range and texture of developmentally appropriate foods and liquids tolerated.
• Assessment of consistency of skills across the feeding opportunity to rule out any negative impact of fatigue on feeding/swallowing safety.
• Impression of airway adequacy and coordination of respiration and swallowing.
• Assessment of developmentally appropriate secretion management, which might include frequency and adequacy of spontaneous dry swallowing and ability to swallow voluntarily.
• Assessment of modifications in bolus delivery and/or use of rehabilitative/habilitative or compensatory techniques on the swallow.
• Consideration for interventions and referrals (e.g., medical or surgical specialists, nutritionist, psychologist or social worker, occupational therapist, physical therapist).

Clinical Evaluation: Infants

The clinical evaluation for infants birth to 1 year of age—including those in the NICU—includes evaluation of prefeeding skills, assessment of readiness for oral feeding, and evaluation of breast- and bottle-feeding ability.

SLPs should have extensive knowledge of embryology, pre-natal and perinatal development, and medical issues common to the preterm and medically fragile newborn as well as knowledge of typical early infant development. A referral to the appropriate medical professional should be made when anatomical or physiological abnormalities are found during the clinical evaluation.

The clinical evaluation of infants typically includes

• a case history that includes gestational and birth history and any pertinent medical history;
• a physical examination that includes a developmental assessment and an assessment of respiratory status;
• the determination of oral feeding readiness;
• an assessment of the infant's ability to engage in non-nutritive sucking (NNS);
• developmentally appropriate clinical assessments of feeding and swallowing behavior (nutritive sucking [NS]), as appropriate;
• an assessment of sucking/swallowing problems and a determination of abnormal anatomy and/or physiology that might be associated with these findings, including a short fenulum (e.g. Francis, Krishnaswami, & McPheeters, 2015; Webb, Hao, & Hong, 2013);
• the identification of additional disorders that may have an impact on feeding and swallowing;
• a determination of the optimal feeding method;
• an assessment of duration of mealtime experience, including the need for supplemental oxygen;
• an assessment of issues related to fatigue and volume limitations;
• an assessment of the effectiveness of parent/caregiver and infant interactions for feeding and communication; and
• consideration of the infant's ability to obtain sufficient nutrition/hydration across settings (e.g., hospital, home, daycare setting).

Readiness For Oral Feeding

Protocols for determining readiness for oral feeding and specific criteria for initiating feeding vary across facilities. In many NICUs, it is a unilateral decision on the part of the neonatologist; in others, the SLP, neonatologist, and nursing staff share observations during their assessments of readiness for oral feedings.

Key criteria to determine readiness for oral feeding include

• physiologic stability—for example, stability of digestive, respiratory, heart rate, and oxygenation parameters;
• motoric stability—stability of muscle tone, flexion, and midline movements; and
• behavioral state (ability to alert) and stability of behavioral state.

Decisions regarding the initiation of oral feeding will be based on recommendations from the medical and therapeutic team with input from the parent and caregivers.

Non-Nutritive Sucking (NNS)

Non-nutritive sucking (NNS)—sucking for comfort without fluid release (e.g., with a pacifier, finger, or recently emptied breast)—does not determine readiness to orally feed, but it is helpful for assessment. NNS patterns can typically be evaluated with skilled observation and without the use of instrumental assessment.

A noninstrumental assessment of NNS includes evaluation of the following:

• The infant's oral structures and functions, including palatal integrity, jaw movement, and tongue movements for cupping and compression. (Note: Lip closure is not required for infant feeding because the tongue typically seals the anterior opening of the oral cavity.)
• The infant's ability to turn the head and open the mouth (rooting) when stimulated on the lips or cheeks and to accept a pacifier into the mouth.
• The infant's ability to use both compression (positive pressure of the jaw and tongue on the pacifier) and suction (negative pressure created with tongue cupping and jaw movement).
• The infant's strength of compression and suction.
• The infant's ability to maintain physiological state during NNS.

Nutritive Sucking (NS)

Once the NNS component of feeding has been assessed, the clinician can determine the appropriateness of nutritive sucking (NS). Any loss of stability in physiologic, motoric, or behavioral state from baseline should be taken into consideration at the time of the assessment.

NS skills are assessed during breastfeeding and bottle feeding, if both modes are going to be used. SLPs need to be sensitive to family values and beliefs regarding bottle feeding and breastfeeding; they consult with parents and collaborate with nurses, lactation consultants, and other medical professionals to help identify parent preferences.

Assessment of NS includes evaluation of the following:

• Sucking/swallowing/breathing pattern—ability to coordinate suck/swallow/breathe pattern
• Efficiency—volume of intake per minute
• Endurance—ability to remain engaged in the feeding to finish the required volumes, while sustaining appropriate feeding patterns

The infant's communication behaviors during feeding can be used as cues to guide dynamic assessment. Cues can communicate the infant's ability to tolerate bolus size, the need for more postural support, and if swallowing and breathing are no longer synchronized. In turn, the caregiver can use these cues to optimize feeding by responding to the infant's needs in a dynamic fashion at any given moment (Shaker, 2013b).

BreastFeeding

SLPs collaborate with mothers, nurses, and lactation consultants prior to assessing breastfeeding skills. This requires working knowledge of breastfeeding strategies to facilitate safe and efficient swallowing and optimal nutrition.

In addition to the clinical evaluation of infants noted above, breastfeeding assessment typically includes evaluation of the

• infant's general health;
• infant's current state, including respiratory rate and heart rate;
• infant's behavior (e.g., positive rooting, willingness to suckle at breast);
• infant's position (e.g., well supported, tucked against mother's body);
• infant's ability to latch onto the breast;
• efficiency and coordination of infant's suck/swallow/breathe pattern;
• health of mother's breast; and
• mother's behavior (e.g., comfort with breastfeeding, confidence handling infant, awareness of infant's cues during feeding).

For an example, see Community management of uncomplicated acute malnutrition in infants < 6 months of age (C-MAMI; 2015) [PDF]

Bottle-Feeding

The assessment of bottle-feeding includes evaluation of the

• infant's general health;
• infant's current state, including respiratory rate and heart rate;
• infant's behavior (willingness to accept nipple);
• efficiency and coordination of infant's suck/swallow/breathe pattern;
• nipple type and form of nutrition (breast milk or formula);
• infant position;
• quantity of intake;
• length of time infant takes for one feeding; and
• infant's response to attempted interventions (e.g., different nipple for flow control, external pacing, different bottle to control air intake, different positions such as side feeding).

Spoon-Feeding

The assessment of spoon-feeding includes evaluation of optimal spoon type and the infant's ability to

• move their head toward the spoon with their mouth open;
• turn their head away from the spoon to show that they have had enough;
• close their lips around the spoon;
• clear food from the spoon with their top lip;
• move food from the spoon to the back of their mouth; and
• attempt to spoon-feed independently.

Clinical Evaluation: Toddlers and Preschool-/School-Age Children

In addition to the areas of assessment noted above, the evaluation for toddlers (ages 1–3 years) and pre-school/school-age children (ages 3–21 years) may include

• review of any past diagnostic test results;
• review of current programs and treatments;
• assessment of current skills and limitations at home and in other day settings;
• assessment of willingness to accept liquids and a variety of foods in multiple food groups;
• consideration of ARFID concerns, such as dependence on diet supplements to meet nutrition needs;
• evaluation of independence and need for supervision and assistance; and
• use of intervention probes to identify strategies that might improve function.

Evaluation and Eligibility in the School Setting

SLPs play a significant role in the management of students with swallowing and feeding problems within school settings. They typically develop and lead the team to address the needs of student with feeding and swallowing issues. They provide assessment and treatment to the student as well as education to parents, teachers, and other professionals who work with the student on a daily basis. See Homer (2016) for in-depth information related to feeding and swallowing services in the schools.

Educational Relevance

The Rehabilitation Act of 1973, Section 504. 29 U.S.C. § 701 (1973) and the Individuals with Disabilities Education Improvement Act (IDEA, 2004) mandate services for health-related disorders that affect the ability of the student to access educational programs and participate fully.

IDEA was enacted to protect the rights of students with disabilities and to ensure that these students receive a free and appropriate public education (FAPE). Although feeding, swallowing and dysphagia are not specifically mentioned in IDEA, the U.S. Department of Education acknowledges that chronic health conditions could make a student eligible for special education and related services if the disorder interferes with the student's strength, vitality, or alertness and limits the student's ability to access the educational curriculum.

Addressing swallowing and feeding disorders may be considered educationally relevant and part of the school system's responsibility for the following reasons:

• Students must be safe while eating in school, including having access to appropriate personnel, food, and procedures to minimize risks for choking and for aspiration while eating.
• Students must be adequately nourished and hydrated so that they can attend to and fully access the school curriculum.
• Students must be healthy (e.g., free from aspiration pneumonia or other illnesses related to malnutrition or dehydration) to maximize their attendance at school.
• Students must develop skills for eating efficiently during meals and snack times so that they can complete these activities with their peers safely and in a timely manner.

Evaluation Process

Each school system's policy manual will include policies and procedures for addressing feeding and swallowing assessment and intervention. The goal of a system-supported process is to develop procedures that are consistent throughout a school district. School-based services typically include a referral process, a screening and evaluation, and the development of a feeding and swallowing intervention plan.

• Referral—The evaluation process begins with a referral to a team of professionals within the school district who are trained in the screening, identification, and treatment of feeding and swallowing disorders. The referral can be initiated by a family member or guardian, school staff member, or outside professional.
  
  Following the initial referral, the school contacts the family member or guardian to discuss the evaluation process, to obtain consent for an evaluation of the student's swallowing and feeding, and to gather information about the child's medical and health history as well as how the student is fed at home and his or her typical diet.

• Screening—Review of the referral is considered part of the screening process. Interviews with the family member or guardian and the student's teacher serve as part of the screening and evaluation process. Following the screening, a comprehensive, interdisciplinary swallowing and feeding evaluation may be recommended.

• Evaluation—The school-based dysphagia team conducts a multidisciplinary observation and clinical evaluation of the student during snack or meal times at school. Modifications and/or strategies are part of the diagnostic process. The information from this evaluation may be used to draft a swallowing and feeding plan—which may be temporary, depending on the need for further diagnostics.

Team Approach

The school-based feeding and swallowing team consists of parents and professionals within the school as well as professionals outside the school (e.g., physicians, dietitians, and psychologists). Core members of the team include the SLP, family/caregiver, classroom teacher, nurse, occupational therapist, physical therapist, and school administrator. Additional members can include the school psychologist, social worker, and cafeteria staff.

The team (a) works together to inform the evaluation process, (b) contributes to the development and implementation of the individualized education program (IEP) for safe swallow, and (c) oversees the day-to-day implementation of the IEP strategies to keep the student safe from aspiration while in school.

If the team determines that medical assessment is advisable prior to initiating a school-based feeding and swallowing program or during the course of a program, the team can recommend that the family seek medical consultation (e.g., for a videofluoroscopic swallowing study [VFSS] referral and/or other medical assessments).

School-based SLPs do not require a doctor's order to perform a clinical evaluation of feeding and swallowing or to implement intervention programs. However, there are times when the SLP needs to contact the student's primary care physician or other health care provider—either through the family or directly, with the family's permission.

Collaboration with outside medical professionals is indicated when medical clearance is needed for an assessment and/or intervention for a student who

• receives part or all of his or her nutrition or hydration via enteral or parenteral tube feeding;
• has a complex medical condition and who experiences a significant change in status;
• has recently been hospitalized with aspiration pneumonia;
• has had a recent choking incident and has required emergency care; and/or
• is suspected of having aspirated food or liquid into the lungs.

See ASHA's resources on interprofessional education/interprofessional practice (IPE/IPP) and collaboration and teaming for guidance on successful collaborative service delivery across settings.

Instrumental Evaluation

Instrumental evaluation is conducted following a clinical evaluation when further information is needed to determine the nature of the swallowing disorder. Instrumental evaluation can also help to determine if swallow safety can be improved by modifying food textures, liquid consistencies, or positioning.

These studies are a team effort and may include the radiologist, radiology technician, and SLP. The SLP or radiology technician typically prepares and presents the barium items, whereas the radiologist records the swallow for visualization and analysis.

The two most commonly used instrumental evaluations of swallowing for the pediatric population are

• videofluoroscopic swallowing study (VFSS) and
• fiberoptic endoscopic evaluation of swallowing without sensory testing (FEES) or with sensory testing (FEEST) to evaluate the laryngeal adductor response (LAR).

During an instrumental assessment of swallowing, the clinician may use information from cardiac, respiratory, and oxygen-saturation monitors to monitor any changes to physiologic or behavioral condition. Other signs to monitor include color changes, nasal flaring, and suck/swallow/breathe patterns.

The roles of the SLP in the instrumental evaluation of swallowing and feeding disorders include

• participating in decisions regarding the appropriateness of these procedures;
• conducting the VFSS and FEES/FEESST instrumental procedures;
• interpreting and applying data from instrumental evaluations to (a) determine the severity and nature of the swallowing disorder and the child's potential for safe oral feeding and (b) formulate feeding and swallowing treatment plans, including recommendations for optimal feeding techniques; and
• being familiar with and using information from diagnostic procedures performed by different medical specialists that yield information about swallowing function—these procedures include manofluorography, cervical auscultation, scintigraphy (which in the pediatric population may also be referred to as radionuclide milk scanning), pharyngeal manometry, 24-hour pH monitoring, and esophagoscopy.

General Considerations for Instrumental Evaluations

Determining the appropriate procedure to use depends on what needs to be visualized and which procedure will be best tolerated by the child. Prior to the instrumental evaluation, clinicians are encouraged to collaborate with the medical team regarding feeding schedules that will maximize feeding readiness during the evaluation.

VFSS may be appropriate for a child who is currently NPO or has never eaten by mouth to determine whether the child has a functional swallow and which types of food he or she can manage. The decision to use VFSS is made with consideration for the child's responsiveness (e.g., acceptance of oral stimulation or tastes on the lips without signs of distress) and the potential for medical complications. Careful pulmonary monitoring during a modified barium swallow is essential to help determine the child's endurance over a typical mealtime.

When conducting an instrumental evaluation, consider the following:

• Anxiety and crying may be expected reactions to any instrumental procedure. Anxiety may be reduced by using distraction (e.g., videos), allowing the child to sit on the parent's or caregiver's lap (for FEES procedures), and decreasing the number of observers in the room.
• Positioning for VFSS depends on the size of the child and his or her medical condition (Arvedson & Lefton-Greif, 1998; Gisel, Applegate-Ferrante, Benson, & Bosma, 1996). Infants under 6 months of age typically require head, neck, and trunk support.
• Infants are obligate nasal breathers, and compromised breathing may result from the placement of a fiberoptic endoscope in one nostril when a nasogastric tube is in place in the other nostril. Clinicians will discuss this with the medical team in order to determine options, including temporary removal of the feeding tube and/or use of another means of swallowing assessment.
• Children are positioned as they are typically fed at home and in a manner that avoids spontaneous or reflex movements that could interfere with the safety of the examination. Modifications to positioning are made as needed and are documented as part of the assessment findings.
• If a natural feeding process (e.g., position, caregiver involvement, and use of familiar foods) cannot be achieved, the results may not represent typical swallow function, and the study may need to be terminated, with results interpreted with caution.

Test Environment

Procedures take place in a child-friendly environment with toys, visual distracters, rewards, and a familiar caregiver, if possible and when appropriate. Various items are available in the room to facilitate success and replicate a typical mealtime experience, including preferred foods, familiar food containers, utensil options, and seating options.

Preparing the Child

• For the child who is able to understand, the clinician explains the procedure, the purpose of the procedure, and the test environment in a developmentally appropriate manner.
• The clinician allows time for the child to acclimate to the room, the equipment, and the professionals who will be present for the procedure.
• For procedures that involve presentation of a solid and/or liquid bolus, the clinician instructs the family to schedule meals and snacks so that the child will be hungry and more likely to accept foods as needed for the study.

If the child has not eaten by mouth (NPO), the clinician allows a period of time for the child to develop the ability to accept and swallow a bolus. For children who have difficulty participating in the procedure, the clinician allows time to bring behaviors under control prior to initiating the instrumental procedure.

Preparing Families

• The clinician provides families and caregivers with information about dysphagia, the purpose for the study, the test procedures, and the test environment.
• The clinician requests that the family provide
  • familiar foods of varying consistencies and tastes that are compatible with contrast material (if facility protocol allows)
  • a specialized seating system from home (including car seat or specialized wheelchair), as warranted and if permitted by the facility; and
  • the child's familiar and preferred utensils, if appropriate.

The primary goals of feeding and swallowing intervention for children are to

• support safe and adequate nutrition and hydration;
• determine the optimum feeding methods and techniques to maximize swallowing safety and feeding efficiency;
• collaborate with family to incorporate dietary preferences;
• attain age-appropriate eating skills in the most normal setting and manner possible (i.e., eating meals with peers in the preschool, meal time with family);
• minimize the risk of pulmonary complications;
• maximize the quality of life; and
• prevent future feeding issues with positive feeding-related experiences to the extent possible, given the child's medical situation.

Consistent with the World Health Organization's (2001) International Classification of Functioning, Disability, and Health (ICF) framework, goals are designed to

• facilitate the individual's activities and participation by promoting safe, efficient feeding;
• capitalize on strengths and address weaknesses related to underlying structures and functions that affect feeding and swallowing;
• modify contextual factors that serve as barriers and enhance those that facilitate successful feeding and swallowing, including development and use of appropriate feeding methods and techniques; and
• promote a meaningful and functional mealtime experience for children and families.

See Person-Centered focus on Function: Pediatric Feeding and Swallowing for examples of goals consistent with ICF.

Medical, surgical, and nutritional considerations are important components in treatment planning. Underlying disease state(s), chronological and developmental age of the child, social and environmental factors, and psychological and behavioral factors also affect treatment recommendations.

For children with complex feeding problems, an interdisciplinary team approach is essential for individualized treatment (McComish et al., 2016). See ASHA's resources on dysphagia teams, interprofessional education/interprofessional practice [IPE/IPP], and collaboration and teaming.

Questions to ask when developing an appropriate treatment plan within the ICF framework include:

Can the child eat and drink safely?

Consider the child's pulmonary status, nutritional status, overall medical condition, mobility, swallowing abilities and cognition, in addition to the child's swallowing function and how these factors affect feeding efficiency and safety.

Can the child receive adequate nutrition and hydration by mouth alone, given length of time to eat, efficiency, and fatigue factors?

If the child cannot meet nutritional needs by mouth, what recommendations need to be made concerning supplemental non-oral intake and/or the inclusion in the child's diet of orally fed supplements? Consider tube feeding schedule, type of pump, rate, calories, and so forth.

How can the child's functional abilities be maximized?

This might involve decisions about whether the individual can safely eat an oral diet that meets nutritional needs, whether that diet needs to be modified in any way, and whether the individual needs compensatory strategies in order to eat the diet. Does the child have the potential to improve swallowing function with direct treatment?

How can the child's quality of life be preserved and/or enhanced?

Consider how long it takes to eat a meal, fear of eating, pleasure obtained from eating, social interactions while eating, and so on (Huckabee & Pelletier, 1999). The family's customs and traditions around mealtimes and food should be respected and explored.

Are there behavioral and sensory-motor issues that interfere with feeding and swallowing?

Do these behaviors result in family/caregiver frustration or increased conflict during meals? Is a sensory-motor–based intervention for behavioral issues indicated?

Treatment Considerations

The health and well-being of the child is the primary concern in treating pediatric feeding and swallowing disorders. Families may have strong beliefs about the medicinal value of some foods or liquids. Such beliefs and holistic healing practices may not be consistent with recommendations made and may be contraindicated.

Treatment selection will depend on the child's age, cognitive and physical abilities, and specific swallowing and feeding problems. Keep in mind that infants and young children with feeding and swallowing disorders, as well as some older children with concomitant intellectual disabilities, often need intervention techniques that do not require them to follow simple verbal or nonverbal instructions. In these cases, intervention might consist of changes in the environment or indirect treatment approaches for improving safety and efficiency of feeding.

Treatment Options

Postural and Positioning Techniques

Postural and positioning techniques involve adjusting the child's posture or position during feeding. These techniques serve to protect the airway and offer safer transit of food and liquid. No single posture will provide improvement to all individuals, and, in fact, postural changes differ between infants and older children. However, the general goal is to establish central alignment and stability for safe feeding.

Techniques include

• chin down—tucking chin down toward neck;
• chin up—slightly tilting head up;
• head rotation—turning head to the weak side to protect the airway;
• upright positioning—90° angle at hips and knees, feet on floor, with supports as needed;
• head stabilization—supported so as to present in chin-neutral position;
• cheek and jaw assist;
• reclining position—e.g., using pillow support or reclined infant seat with trunk and head support; and
• side-lying positioning for infants.

Diet Modifications

Diet modifications consist of altering the viscosity, texture, temperature, portion size, or taste of a food or liquid to facilitate safety and ease of swallowing. Typical modifications may include thickening thin liquids, softening, cutting/chopping, or pureeing solid foods. Taste or temperature of a food may be altered to provide additional sensory input for swallowing.

Diet modifications incorporate individual and family preferences, to the extent feasible. Consult with families regarding safety of medical treatments, such as swallowing medication in liquid or pill form, which may be contraindicated by the disorder. Diet modifications should consider the nutritional needs of the child in order to avoid undernutrition and malnutrition.

Precaution

The U.S. Food and Drug Administration (FDA) has cautioned consumers about the use of commercial, gum-based thickeners for infants from birth to 1 year of age, especially when the product is used to thicken breast milk. SLPs should be aware of these cautions and consult as appropriate with their facility to develop guidelines for using thickened liquids with infants. See FDA consumer cautions (U. S. Food and Drug Administration, 2017).

Equipment and Utensils

Adaptive equipment and utensils may be used with children who have feeding problems to foster independence with eating and increase swallow safety by controlling bolus size or achieving the optimal flow rate of liquids.

Examples of adaptive equipment include

• modified nipples;
• cut out cups;
• weighted forks and spoons;
• angled forks and spoons;
• sectioned plates;
• non-tip bowls; and
• Dycem® to prevent plates and cups from sliding.

Maneuvers

Maneuvers are strategies used to change the timing or strength of movements of swallowing (Logemann, 2000). Some maneuvers require following multistep directions and may not be appropriate for young children and/or older children with cognitive impairments. Examples of maneuvers include the following:

• Effortful swallow—posterior tongue base movement is increased to facilitate bolus clearance.
• Masako, or tongue hold—tongue is held forward between the teeth while swallowing; this is performed without food or liquid in the mouth to prevent coughing or choking.
• Mendelsohn maneuver—elevation of the larynx is voluntarily prolonged at the peak of the swallow to help the bolus pass more efficiently through the pharynx and to prevent food/liquid from falling into the airway.
• Supraglottic swallow—vocal folds are usually closed by voluntarily holding breath before and during swallow in order to protect the airway.
• Super-supraglottic swallow—effortful breath hold tilts the arytenoid forward, which closes the airway entrance before and during the swallow.

Oral–Motor Treatments

Oral–motor treatments include stimulation to—or actions of—the lips, jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles. Oral–motor treatments range from passive (e.g., tapping, stroking, and vibration) to active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises). Oral–motor treatments are intended to influence the physiologic underpinnings of the oropharyngeal mechanism in order to improve its functions. Some of these interventions can also incorporate sensory stimulation.

Feeding Strategies

Feeding strategies include pacing and cue-based feeding.

Pacing—moderating the rate of intake by controlling or titrating the rate of presentation of food or liquid and the time between bites or swallows. Feeding strategies for children may include alternating bites of food with sips of liquid or swallowing 2–3 times per bite or sip. For infants, pacing can be accomplished by limiting the number of consecutive sucks. Strategies that slow the feeding rate may allow for more time between swallows to clear the bolus and may support more timely breaths.

Cue-based feeding—relies on cues from the infant, such as lack of active sucking, passivity, pushing the nipple away, or a weak suck. These cues typically indicate that the infant is disengaging from feeding and communicating the need to stop. They also provide information about the infant's physiologic stability, which underlies the coordination of breathing and swallowing, and they guide the caregiver to intervene to support safe feeding. When the quality of feeding takes priority over the quantity ingested, feeding skill develops pleasurably and at the infant's own pace. As a result, intake is improved (Shaker, 2013a).

Most NICUs have begun to move away from volume-driven feeding to cue-based feeding. Rather than setting a goal to empty the bottle, the feeding experience is viewed as a partnership with the infant. In the NICU, the SLP plays a critical role, supporting parents and other caregivers to understand and respond accordingly to the infant's communication during feeding.

Sensory Stimulation Techniques

Sensory stimulation techniques vary and may include thermal–tactile stimulation (e.g., using an iced lemon glycerin swab) or tactile stimulation (e.g., using a NUK brush) applied to the tongue or around the mouth. Children who demonstrate aversive responses to stimulation may need approaches that reduce the level of sensory input initially, with incremental increases as the child demonstrates tolerance. Sensory stimulation may be needed for children with reduced responses, overactive responses, or limited opportunities for sensory experiences.

Behavioral Interventions

Behavioral interventions are based on principles of behavioral modification and focus on increasing appropriate actions or behaviors—including increasing compliance—and reducing maladaptive behaviors related to feeding. Behavioral interventions include such techniques as antecedent manipulation, shaping, prompting, modeling, stimulus fading, and differential reinforcement of alternate behavior, as well as implementation of basic mealtime principles (e.g., scheduled mealtimes in a neutral atmosphere with no food rewards).

Biofeedback

Biofeedback includes instrumental methods (e.g., surface electromyography, ultrasound, nasendoscopy) that provide visual feedback during feeding and swallowing. Children with sufficient cognitive skills can be taught to interpret this visual information and make physiological changes during the swallowing process.

Intraoral Prosthetics and Appliances

Intraoral prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize the intraoral cavity by providing compensation or physical support for children with congenital abnormalities (e.g., cleft palate) or damage to the oropharyngeal mechanism. With this support, swallowing efficiency and function may be improved.

Intraoral appliances (e.g., palatal plates) are removable devices with small knobs that provide tactile stimulation inside the mouth to encourage lip closure and appropriate lip and tongue position for improved functional feeding skills.

Referral to dental professionals for assessment and fitting of these devices.

Tube Feeding

Tube feeding includes alternative avenues of intake such as nasogastric [NG] tube, transpyloric tube (placed in the duodenum or jejunum), or gastrostomy (G-tube placed in the stomach or GJ-tube placed in the jejunum). These approaches may be considered if the child's swallowing safety and efficiency cannot reach a level of adequate function or does not adequately support nutrition and hydration. In these instances, the swallowing and feeding team will (a) consider the optimum tube-feeding method that best meets the child's needs and (b) determine whether the child will need tube feeding for a short or extended period of time. Alternative feeding does not preclude the need for feeding-related treatment.

Treatment in the NICU and Infant Care Units

Clinicians working in the NICU need to be aware of the multidisciplinary nature of this practice area, the variables that influence infant feeding, and process for developing appropriate treatment plans in this setting. The NICU is considered an advanced practice area, and inexperienced SLPs should be aware of the risks of working in this setting.

In all cases, the SLP must have an accurate understanding of the physiologic mechanism driving the symptomatic feeding problems seen in this population. This understanding gives the SLP the necessary knowledge to choose appropriate treatment interventions and provides a solid rationale for their use in the NICU.

Communication

In their role as communication specialists, SLPs monitor the infant for stress cues and teach parents and other caregivers to recognize and interpret the infant's communication signals. SLPs treating preterm and medically fragile infants must be well versed in typical infant behavior and development so that they can recognize and interpret changes in behavior that provide cues that signal well-being or stress during feeding.

Behaviors can include changes in the following:

• Autonomic system—pattern of respiration (pauses, tachypnea), color changes (red, pale, dusky, mottled), and visceral signs (e.g., spit up, gag, burp).
• Movement—postural alignment (hyperflexed, extended); muscle tone (flaccid, hypertonicity); movement patterns in extremities, trunk, head, and face; and level of motor activity.
• State—the range of available states of consciousness (i.e., deep sleep, quiet alert, and crying), the smoothness of transition between them, and the clarity of their expression.
• Attention—the infant's ability to orient and focus on environmental stimuli, such as face, sounds, or objects.

Readiness For Oral Feeding

Readiness for oral feeding in the preterm or acutely ill full-term infant is associated with (a) the infant's ability to come into and maintain awake states and to coordinate breathing with sucking and swallowing (McCain, 1997) and (b) the presence or absence of apnea. Apnea is strongly correlated with longer transition time to full oral feeding (Mandich, Ritchie, & Mullett, 1996).

Supportive interventions to facilitate early feeding and/or to promote readiness for feeding include kangaroo mother care (KMC), nonnutritive sucking (NNS), and feeding protocols.

For children who have been NPO for an extended period of time, it is important to consult with the physician to determine when to begin oral feeding. When exploring this option, it is also important to consider any behavioral and/or sensory components that may influence feeding.

Kangaroo Mother Care (KMC)

Kangaroo mother care (KMC)—skin-to-skin contact between a mother and her newborn infant—can be an important factor in helping the infant achieve readiness for oral feeding, particularly breastfeeding. Other benefits of KMC include temperature regulation, promotion of breastfeeding, parental empowerment and bonding, stimulation of lactation, and oral stimulation for the promotion of oral feeding ability.

Non-Nutritive Sucking (NNS) Facilitation

Non-nutritive sucking (NNS) involves allowing an infant to suck without taking milk, either at the breast (after milk has been expressed) or with the use of a pacifier. It is used as a treatment option to encourage eventual oral intake. The SLP providing and facilitating oral experiences with NNS must take great care to ensure that the experiences are positive and do not elicit stress or other negative consequences. The SLP also teaches parents and other caregivers to provide positive oral experiences and to recognize and interpret the infant's cues during NNS.

Feeding Protocols

Feeding protocols include those that consider infant cues (i.e., responsive feeding) and those that are based on a schedule (i.e., scheduled feeding).

The following factors are considered prior to initiating and systematically advancing oral feeding protocols:

• alertness,
• demand for feeding,
• infant cues that signal stress,
• neurodevelopmental level, and
• general health status.

Treatment for Toddlers and Older Children

The management of feeding and swallowing disorders in toddlers and older children may require a multidisciplinary approach—especially for children with complex medical conditions.

Similar to treatment for infants in the NICU, treatment for toddlers and older children takes a number of factors into consideration, including the following:

• Readiness for oral feeding—Toddlers and older children who are beginning to eat orally for the first time or after an extended period of non-oral feeding will need time to become comfortable in the presence of food and to explore food without experiencing physiological responses (e.g., for children with significant gastrointestinal problems).
• Communication—In terms of communication, SLPs can help caregivers understand emerging vocabulary related to food (e.g., names of foods and various flavors) as well as how children might be using feeding behaviors (e.g., food refusal responses) to communicate.
• Physical conditions—Treatment for children with conditions and disorders that affect movement (e.g., cerebral palsy or muscular dystrophy) will need to take into consideration length of time to fatigue, optimal feeding methods, and positioning to maximize safe feeding and swallowing.

Treatment in the School Setting

Management of students with feeding and swallowing disorders in the schools addresses the impact of the disorder on the student's educational performance and promotes the student's safe swallow in order to avoid choking and/or aspiration pneumonia. Students with recurrent pneumonia may miss numerous school days, which has a direct impact on their ability to access the educational curriculum. In addition to an IEP or 504 Plan, other documentation may be required, including the following:

• Swallowing and feeding plan—includes training, service delivery, and daily management. A plan typically includes recommendations and guidelines on positioning, equipment, diet and food preparation, feeding techniques, and precautions. Personnel will require adequate education and training by the SLP related to the swallowing and feeding plan. It is important to verify and document the educational training within the plan.

• Individual health plan (IHP)—is drawn up at the IEP conference by the school nurse. The IHP provides information on specific precautions related to the student's feeding and swallowing and is kept in an easily accessible place in the classroom. Classroom personnel are trained on the IHP. The swallowing and feeding plan may be attached to the IHP for additional information on the student's swallowing and feeding safety precautions.

Transitioning Adolescents and Adults

Feeding and swallowing challenges can persist well into adolescence and adulthood. Precautions, accommodations, and adaptations must be considered and implemented as students transition to post-secondary settings. See ASHA's resource on transitioning youth for information about transition planning.

Periodic assessment and monitoring of significant changes are necessary to ensure ongoing swallow safety and adequate nutrition throughout adulthood. A risk assessment for choking and an assessment of nutritional status should be considered as part of a routine examination for adults with disabilities, particularly those with a history of feeding and swallowing problems. See, for example, Moreno Villares (2014) and Thacker, Abdelnoor, Anderson, White, & Hollins, (2008).

Service Delivery

See the Service Delivery section of the Pediatric Feeding and Swallowing Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

In addition to determining the type of treatment that is optimal for the child with feeding and swallowing problems, SLPs consider other service delivery variables that may affect treatment outcomes, including format, provider, dosage, and setting. Decisions are made based on the child's needs, his or her family's views and preferences, and the setting where services are provided.

Format

Format refers to the structure of the treatment session (e.g., group and/or individual). The appropriateness of the treatment format often depends on the child's age, the type and severity of the feeding or swallowing problem, and the service delivery setting.

Provider

Provider refers to the person providing treatment (e.g., SLP, occupational therapist, or other feeding specialist). Recommended practices follow a collaborative process that involves an interdisciplinary team including the child, family, caregivers, and other related professionals. When treatment incorporates accommodations, modifications, and supports in everyday settings, SLPs often provide training and education in how to use strategies to facilitate safe swallowing.

Dosage

Dosage refers to the frequency, intensity, and duration of service. Dosage depends on individual factors, including the child's medical status, nutritional needs, and readiness for oral intake.

Setting

Setting refers to the location of treatment and varies across the continuum of care (e.g., NICU, intensive care unit, inpatient acute care, outpatient clinic, home, or school).

ASHA Resources

• Aerosol Generating Procedures
• Dysphagia Management for School Children: Dealing With Ethical Dilemmas
• Dysphagia Teams
• Ethical Issues in Swallowing
• Feeding and Swallowing Disorders in Children [Consumer Information]
• International Dysphagia Diet Standardisation Initiative (IDDSI)
• Interprofessional Education/Interprofessional Practice [IPE/IPP]
• Medicaid Reimbursement in Schools
• Pediatric Assessment Templates
  • User's Guide to Pediatric Clinical Feeding Assessment Templates [PDF]
  • Pediatric Clinical Assessment Template (Liquids only) [PDF]
  • Pediatric Clinical Assessment Template (Liquids, semi-solid and solid foods) [PDF]
  • Videofluoroscopic Swallowing Exam (infants consuming liquids only) [PDF]
  • Videofluoroscopic Swallowing Exam (children consuming purees through table foods) [PDF]
• Person- and Family-Centered Care
• Pick the Right Code for Pediatric Dysphagia
• Swallowing and Feeding Team Referral Plan (Sample Form) [PDF]
• Transitioning Youth
• Videofluoroscopic Swallow Study (VFSS)
• Fiberoptic Endoscopic Evaluation of Swallowing: Without Sensory testing (FEES) or With Sensory Testing (FEESST)

Other Resources

This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Academy of Pediatrics Policy Statement—Prevention of Choking Among Children [PDF]
• Developmental Stages in Infant and Toddler Feeding [PDF]
• feeding matters
• International Commission on Radiological Protection (ICRP)
• La Leche League International
• Community management of uncomplicated acute malnutrition in infants < 6 months of age (C-MAMI; 2015) [PDF]
• National Foundation of Swallowing Disorders
• Pediatric Feeding Association
• RadiologyInfo.org: Video Fluoroscopic Swallowing Exam (VFSE)

American Psychiatric Association. (2016). Feeding and eating disorders [DSM-5 Selections]. Arlington, VA: Author.

American Speech-Language-Hearing Association. (2013). Speech-language pathology assistant scope of practice [Scope of Practice]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.

Arvedson, J. C. (2008). Assessment of pediatric dysphagia and feeding disorders: Clinical and instrumental approaches. Developmental Disabilities Research Reviews, 14, 118–127.

Arvedson, J. C., & Brodsky, L. (2002). Pediatric swallowing and feeding: Assessment and management. Albany, NY: Singular Publishing.

Arvedson, J. C., & Lefton-Greif, M. A. (1998). Pediatric videofluoroscopic swallow studies: A professional manual with caregiver guidelines. San Antonio, TX: Communication Skill Builders.

Bhattacharyya, N. (2015). The prevalence of pediatric voice and swallowing problems in the United States. The Laryngoscope, 125, 746–750.

Beckett, C. M., Bredenkamp, D., Castle, J., Groothues, C., O'Connor T. G., Rutter, M., & The English and Romanian Adoptees (ERA) Study Team. (2002). Behavior patterns associated with institutional deprivation: A study of children adopted from Romania. Journal of Developmental and Behavioral Pediatrics, 23, 297–303.

Benfer, K. A., Weir, K. A., Bell, K. L., Ware, R .S., Davies, P. S. W., & Boyd, R. N. (2014). Oropharyngeal dysphagia in preschool children with cerebral palsy: Oral phase impairments. Research in Developmental Disabilities, 35, 3469–3481.

Black, L. I., Vahratian, A., & Hoffman, H. J. (2015). Communication disorders and use of intervention services among children aged 3-17 years: United States, 2012 [NHS Data Brief No. 205]. Hyattsville, MD: National Center for Health Statistics.

Brackett, K., Arvedson, J. C., & Manno, C. J. (2006). Pediatric feeding and swallowing disorders: General assessment and intervention. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 15, 10–14.

Calis, E. A. C., Veuglers, R., Sheppard, J. J., Tibboel, D., Evenhuis, H. M., & Penning, C. (2008). Dysphagia in children with severe generalized cerebral palsy and intellectual disability. Developmental Medicine & Child Neurology, 50, 625–630.

Caron, C. J. J. M., Pluijmers, B. I., Joosten, K. F. M., Mathijssen, I. M. J., van der Schroeff, M. P., Dunaway, . . . Koudstaal, M. J. (2015). Feeding difficulties in craniofacial microsomia: A systematic review. International Journal of Oral & Maxillofacial Surgery, 44, 732–737.

Davis-McFarland, E. (2008). Family and cultural issues in a school swallowing and feeding program. Language, Speech, and Hearing Services in Schools, 39, 199–213.

de Vries, I. A. C, Breugem, C. C., van der Heul, A. M. B., Eijkemans, M. J. C., Kon, M., & Mink van der Molen, A. B. (2014). Prevalence of feeding disorders in children with cleft palate only: A retrospective study. Clinical Oral Investigations, 18, 1507–1515.

Dodrill, P. (2017). Pediatric feeding assessments and interventions. Rockville, MD: American Speech-Language-Hearing Association.

Eddy, K. T., Thomas, J. J., Hastings, E., Edkins, K., Lamont, E., Nevins, C. M., . . . Becker, A. E. (2015). Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network. International Journal of Eating Disorders, 48, 464–470.

Erkin, G., Culha, C., Sumru, K., & Gulsen, E. (2010). Feeding and gastrointestinal problems in children with cerebral palsy. International Journal of Rehabilitation Research, 33, 218–224.

Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., . . . Walsh, B. T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: A “new disorder” in DSM-5. Journal of Adolescent Health, 55, 49–52.

Francis D. O., Krishnaswami S., & McPheeters M. (2015). Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics, 135, e1467-e1474.

Gisel, E. G. (1988). Chewing cycles in 2- to 8-year-old normal children: A developmental profile. American Journal of Occupational Therapy, 42, 40–46.

Gisel, E. G., Applegate-Ferrante, T., Benson, J., & Bosma, J. F. (1996). Positioning for infants and children for videofluoroscopic swallowing function studies. Infants and Young Children, 8, 58–64.

Homer, E. M. (2016). Management of swallowing and feeding disorders in schools. San Diego, CA: Plural.

Huckabee, M. L., & Pelletier, C. A. (1999). Management of adult neurogenic dysphagia. San Diego, CA: Singular.

Individuals with Disabilities Education Improvement Act, 20 U.S.C. § 1400 (2004). Retrieved from https://sites.ed.gov/idea/

Johnson, D. E., & Dole, K. (1999). International adoptions: Implications for early intervention. Infants and Young Children, 11, 34–45.

Le Révérend, B. J., Edelson, L. R., & Loret, C. (2014). Anatomical, functional, physiological and behavioural aspects of the development of mastication in early childhood. British Journal of Nutrition, 111, 403–414.

Lefton-Greif, M. (2008). Pediatric dysphagia. Physical Medicine and Rehabilitation Clinics of North America, 19, 837–851.

Lefton-Greif, M. A., Carroll, J. L., & Loughlin, G. M. (2006). Long-term follow-up of oropharyngeal dysphagia in children without apparent risk factors. Pediatric Pulmonology, 41, 1040–1048.

Lefton-Greif, M. A., McGrattan, K. E., Carson, K. A., Pinto, J. M., Wright, J. M., & Martin-Harris, B. (2017). First steps towards development of an instrument for the reproducible quantification of oropharyngeal swallow physiology in bottle-fed children. Dysphagia, 33, 76–82.

Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders. Austin, TX: Pro-Ed.

Logemann, J. A. (2000). Therapy for children with swallowing disorders in the educational setting. Language, Speech, and Hearing Services in Schools, 31, 50–55.

Mandich, M. B., Ritchie, S. K., & Mullett, M. (1996). Transition times to oral feeding in premature infants with and without apnea. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 25, 771–776.

Manikam, R., & Perman, J. A. (2000). Pediatric feeding disorders. Journal of Clinical Gastroenterology, 30, 34–46.

McCain, G. C. (1997). Behavioral state activity during nipple feedings for preterm infants. Neonatal Network, 16, 43–47.

McComish, C., Brackett, K., Kelly, M., Hall, C., Wallace, S., & Powell, V. (2016). Interdisciplinary feeding team: A medical, motor, behavioral approach to complex pediatric feeding problems. MCN: The American Journal of Maternal/Child Nursing, 41, 230–236.

Moreno Villares, J. M. (2014). Transition to adult care for children with chronic neurological disorders: Which is the best way to make it? Nutricion Hospitalaria, 29, 32–37.

National Center for Health Statistics. (2010). Number of all-listed diagnoses for sick newborn infants by sex and selected diagnostic categories [Data File]. Retrieved from https://www.cdc.gov/nchs/data/nhds/8newsborns/2010new8_numbersick.pdf

Newman, L. A., Keckley, C., Petersen, M. C., & Hamner, A. (2001). Swallowing function and medical diagnoses in infants suspected of dysphagia. Pediatrics, 108, e106–e106.

Rehabilitation Act of 1973, Section 504. 29 U.S.C. § 701 (1973). Retrieved from https://www.dol.gov/oasam/regs/statutes/sec504.htm

Reid, J., Kilpatrick, N., & Reilly, S. (2006). A prospective, longitudinal study of feeding skills in a cohort of babies with cleft conditions. The Cleft Palate–Craniofacial Journal, 43,702–709.

Shaker, C. S. (2013a). Cue-based feeding in the NICU: Using the infant's communication as a guide. Neonatal Network, 32, 404–408.

Shaker, C. S. (2013b, February 1). Reading the feeding. The ASHA Leader, 18, 42–47.

Sharp, W. G., Berry, R. C., McCracker, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., . . . Jacques, D. C. (2013). Feeding problems and nutrient intake in children with autism disorders: A meta-analysis and comprehensive review of the literature. Journal of Autism and Developmental Disorders, 43, 2159–2173.

Thacker, A., Abdelnoor, A., Anderson, C., White, S., & Hollins, S. (2008). Indicators of choking risk in adults with learning disabilities: A questionnaire survey and interview study. Disability and Rehabilitation, 30, 1131–1138.

U.S. Food and Drug Administration. (2017). FDA expands caution about simply thick. Rockville, MD: Author.

Webb, A. N., Hao, W., & Hong, P. (2013). The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. International Journal of Pediatric Otorhinolaryngology, 77, 635-646.

Wilson, E. M., & Green, J. R. (2009). The development of jaw motion for mastication. Early Human Development, 85, 303–311.

World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.

Acknowledgement

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Pediatric Dysphagia page:

• Joan C. Arvedson, PhD, CCC-SLP
• Donna K. Edwards, MA, CCC-SLP
• Amy S. Faherty, MS, CCC-SLP
• Memorie M. Gosa, PhD, CCC-SLP
• Maureen A. Lefton-Greif, MA, PhD, CCC-SLP
• Emily M. Homer, MA, CCC-SLP
• Randy M. Kurjan, MS, CCC-SLP
• Kara M. Larson, MS, CCC-SLP
• Sara S. Plager, MEd, CCC-SLP
• Erin E. Redle, PhD, CCC-SLP
• Eugenia M. Rogers, MA, CCC-SLP
• Erin Ross, PhD, CCC-SLP
• Jeanne L. Saavedra, MHS, CCC-SLP
• Panayiota A. Senekkis-Florent, PhD, CCC-SLP 
• Catherine S. Shaker, MS, CCC-SLP
• Justine Joan Sheppard. PhD, CCC-SLP
• Beth I. Solomon, MS, CCC-SLP
• Nancy B. Swigert, MA, CCC-SLP

In addition, ASHA thanks the members of the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit (NICU); Special Interest Division 13, Swallowing and Swallowing Disorders (Dysphagia) Committee on Cross-Training; and the Working Group on Dysphagia in Schools, whose work was foundational to the development of this content. 

Members of the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit included Justine J. Sheppard (chair), Joan C. Arvedson, Alexandra Heinsen-Combs, Lemmietta G. McNeilly, Susan M. Moore, Meri S. Rosenzweig Ziev, and Diane R. Paul (ex officio).  Alex F. Johnson and Celia Hooper served as monitoring officers (vice presidents for speech-language pathology practices, 2000-2002 and 2003-2005, respectively). 

Members of the Swallowing and Swallowing Disorders (Dysphagia) Committee on Cross-Training included Caryn Easterling, Maureen Lefton-Greif, Paula Sullivan, Nancy Swigert, and Janet Brown (ASHA staff liaison).  Celia Hooper, vice president for professional practices in speech-language pathology (2003-2005), served as monitoring vice president.

Members of the Working Group on Dysphagia in Schools included Emily M. Homer (chair), Sheryl C. Amaral, Joan C. Arvedson, Randy M. Kurjan, Cynthia R. O'Donoghue, Justine Joan Sheppard, and Janet E. Brown (ASHA liaison).  Brian B. Shulman, vice president for professional practices in speech-language pathology, served as the monitoring officer.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association (n.d). Pediatric Dysphagia. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Pediatric-Dysphagia/.